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General NPI Number Information
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NPI Number | 1871700088
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Entity Type | Organization
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Legal Business Name | MEMORY DISORDERS CLINIC
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1245 15TH ST N
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City | SAINT CLOUD
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State | MN
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Zip | 56303-1802
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Country | US
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Telephone | 320-203-2093
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Fax |
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Provider Business Mailing Address
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Address Line | 10915 264TH ST
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City | SAINT CLOUD
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State | MN
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Zip | 56301-9411
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Country | US
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Telephone | 320-293-2128
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. SANDRA WENNER
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Credential |
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Telephone | 320-203-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 100395
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License Number State | MN
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